September, 2009 - SUPPORT Summary of a systematic review | print this article |

Does expanding the role of outpatient pharmacists improve healthcare delivery and patient outcomes?

Over the past several years the roles of pharmacists have expanded from dispensing prescriptions to providing other services to patients and health professionals. These roles include identifying, resolving and preventing drug-related problems and also the provision of ‘non-product related’ health promotion services, such as distributing educational materials.

Key messages

  • Pharmacists services targeted at patients may decrease the use of specific health services – such as hospital admissions and ambulatory care visits – and may slightly improve patients’ compliance with drug therapy
  • Pharmacists services targeted at health professionals may slightly decrease prescribing and costs of specific drugs, but it is not known whether it improves the appropriateness of drug prescribing
  • The operating costs of pharmacists services targeted at health professionals may slightly exceed the saving in drug costs
  • Differences in health systems, patients and physician attitudes towards pharmacists, training of pharmacists and legal restrictions may limit the applicability of the findings from this review, especially because all but two of the studies were conducted at single sites in the United States

Who is this summary for?

This summary includes:

  • Key findings from research based on a systematic review
  • Considerations about the relevance of this research for low income countries

Not included:

  • Recommendations
  • Additional evidence not included in the systematic review
  • Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Prescribing is one of the main interventions delivered by physicians in outpatient settings. However, there is growing concern about its appropriateness mainly because inappropriate prescribing can lead to increases in pharmaceutical expenditures without improvements in patient outcomes and may have adverse effects. Over the past several years, the roles of pharmacists have expanded from packaging and dispensing prescriptions and over the counter medications to working with other health professionals and the public. These expanded roles include identifying, resolving and preventing drugrelated problems. In addition to assisting patients directly, pharmacists can also provide services to other health professionals, including reviewing drug regimens and advising physicians about the appropriate use of medications. Pharmacists may also provide ‘nonproduct related’ health promotion services, such as distributing educational materials.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.



About the systematic review underlying this summary

About the certainty of the 
evidence (GRADE)


High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.


Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.


Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.


Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The review included 25 studies conducted in high-income settings, mostly in the US. Considering that the situation for some LMIC is one in which no comparable service is currently delivered, the two comparisons chosen for this summary were those where the control group was the delivery of no comparable service. Sixteen studies assessed the effects of pharmacists services targeted at patients and nine of services targeted at health professionals.

1) Pharmacists services targeted at patients compared to the delivery of no comparable service

The interventions involved a number of different activities such as patient education, management of patients’ drug therapy, drug monitoring, patient follow-up and home visits. They tended to be multiple interactions conducted over a period of 2 to 29 months.

  • Pharmacists services targeted at patients may decrease the use of specific health services such as hospital admissions and ambulatory care visits 
  • It is not known whether pharmacists services targeted at patients have an specific effect on the type of ambulatory care visits (primary care vs. specialty care)
  • Pharmacists services targeted at patients may slightly improve patients’ compliance with drug therapy 
  • The operating costs of the intervention may slightly exceed the saving in drug costs

2) Pharmacists services targeted at health professionals compared to the delivery of no comparable service

The intervention consisted mostly of outreach visits carried out by the pharmacists or the use of computer generated drug profiles. It tended to be single brief interactions (less than an hour) and conducted over a period of 1 to 17 months. The aims of most of these interventions were to decrease the total number of drugs, the number of inappropriate drugs, or the cost of drugs prescribed by physicians.

  • Pharmacists services targeted at health professionals may slightly decrease prescribing and costs of specific drugs targeted by the intervention
  • It is not known whether this intervention improved the appropriateness of drug prescribing.
  • The operating costs of the intervention may slightly exceed the saving in drug costs.

Relevance of the review for low-income countries

Additional information

Related literature

Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet 2008; 371: 668–74.

 

World Health Organization. Task Shifting: Global Recommendations and Guidelines. Geneva: WHO, 2008. www.who.int/healthsystems/task_shifting/en/

 

This summary was prepared by

Tomás Pantoja, Faculty of Medicine, Pontificia Universidad Católica de Chile

 

Conflict of interest

None declared. For details, see: http://www.support-collaboration.org/summaries/coi.htm

 

Acknowledgements

This summary has been peer reviewed by: Lisa Bero, USA; Angeni Bheekie, South Africa; Fatima Suleman,South Africa; Tracey Perez Koehlmoos, Bangladesh.

 

This summary should be cited as

Pantoja T. Does expanding the role of outpatient pharmacists improve healthcare delivery and patient outcomes?. A SUPPORT Summary of a systematic review. September 2009. http://www.supportcollaboration.org/summaries.htm



About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

To receive e-mail notices of new SUPPORT summaries or provide feedback on this summary, go to: www.supportsummaries.org/contact

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